- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $245.47 / $446.68
| Professional | | $114.82 | $245.47 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $467.74 / $1,000.00
| Professional | | $398.11 | $467.74 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $269.15 / $436.52
| Professional | | $158.49 | $269.15 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $1,000.00
| Professional | | $457.09 | $457.09 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $288.40 / $616.60
| Professional | | $120.23 | $288.40 | $616.60 |